Clinical Review Nurse - Prior Authorization

Position Title: Clinical Review Nurse - Prior Authorization

Work Location: Fully Remote (Must work AZ time and reside in compact state with AZ or Compact License)

Assignment Duration: 3 months

Work Schedule: M-F, 8AM-5PM AZ time | 3 weeks training (No time off, ON CAMERA)

Position Summary:

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  Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage.

  
  
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  Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

  
  
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  May call a provider for more information but will not be in contact with members.

  
  

Key Responsibilities:

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  Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria

  
  
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  Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care

  
  
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  Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member

  
  
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  Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care

  
  
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  Assists with service authorization requests for a member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities

  
  
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  Collects, documents, and maintains all member's clinical information in health management systems to ensure compliance with regulatory guidelines

  
  
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  Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members

  
  
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  Provides feedback on opportunities to improve the authorization review process for members

  
  
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  Performs other duties as assigned

  
  
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  Complies with all policies and standards

  
  

Qualification & Experience:

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  Requires Graduate from an Accredited School of Nursing RN/LPN or Bachelor's degree in Nursing and 2 - 4 years of related experience

  
  
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  Licensure: LPN, RN, or BSN

  
  
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  2-4 years of experience in health authorizations, medical terminology, HIPAA guidelines